Estrogen-only, combined, transdermal, systemic, vaginal, bioidentical — the vocabulary of hormone therapy is a wall of terms that all sound interchangeable and are not. This is a plain map of the landscape, from a publication that sells none of it, so your conversation with a clinician starts further along.

Where we stand: Menova is an independent publication. We sell no hormones and are not a medical provider, so we have no reason to nudge you toward anything. This is general education, not medical advice.

Hormone therapy — HRT, or MHT for menopausal hormone therapy — comes down to two questions: which hormones, and how they get into your body. The second one turns out to matter more than most women are told.

Which hormones

Estrogen is the active ingredient. It treats the classic symptoms — hot flashes, night sweats, disrupted sleep — and helps with vaginal dryness. The estrogen used today is almost always estradiol, chemically identical to what your ovaries produced.

A progestogen is added for one reason: to protect your uterus. Estrogen acting on the uterine lining unopposed causes it to build up, raising the risk of endometrial hyperplasia and endometrial cancer. A progestogen prevents that.

Which gives the rule clinicians use:

  • Uterus intact → systemic estrogen is combined with a progestogen
  • Hysterectomy → estrogen-only is standard, since there is no lining to protect

That second case has a real advantage worth knowing: the small breast cancer increase seen in trials was associated with combined therapy, and progestogen side effects — bloating, breast tenderness, mood changes — are a common reason women stop. See hysterectomy and menopause and breast cancer risk in real numbers.

Testosterone occasionally enters the conversation. Its only evidence-based indication in women is distressing low sexual desire after menopause, and there is no FDA-approved female product — see testosterone for women.

Which progestogen, and which regimen

Two distinctions that determine how well you tolerate it.

Micronized progesterone is structurally identical to your own hormone and available as an FDA-approved capsule, usually taken at night — the drowsiness is used deliberately. Progestins are synthetic compounds acting on the same receptors. Limited observational evidence suggests micronized progesterone may compare more favourably on breast and cardiovascular measures, though this is suggestive rather than settled.

A hormonal IUD is a third option, delivering progestogen directly to the lining — and simultaneously providing contraception and reducing heavy bleeding, which is why it suits perimenopause particularly well.

Cyclical or continuous depends on your stage:

  • Still having periods → cyclical, with progestogen 10–14 days a month and a monthly bleed. Continuous therapy while you are still cycling tends to cause erratic breakthrough bleeding
  • Postmenopausal → continuous combined, aiming for no bleeding at all

Getting this wrong for your stage is one of the most common reasons women conclude "HRT doesn't work for me." See progesterone in menopause.

The route: the decision that changes your risk

This is the most actionable information in menopause care.

  • Oral (tablet). Familiar and simple. Because it is swallowed, it passes through the liver first, which alters production of clotting factors
  • Patch (transdermal). Worn on the skin, changed once or twice weekly. Absorbed directly into the bloodstream, skipping that first pass
  • Gel or spray (transdermal). Applied daily, same mechanism, with easier dose adjustment

Oral estrogen is associated with a small increase in venous thromboembolism and stroke. Transdermal estrogen at standard doses has not been shown to carry the same increase, because it avoids first-pass liver metabolism. NICE guidance and menopause societies both highlight this distinction.

For symptom relief the two are similarly effective — so the choice usually turns on your risk factors, not on one being better. Transdermal is generally preferred if you have a clot history or thrombophilia, migraine with aura, BMI over 30, or cardiovascular risk factors. See HRT and blood clot risk and menopause and migraines.

Practical differences people ask about: patches can irritate skin or peel in heat and humidity, and rotating the site helps. Gels need drying time and care not to transfer to others. Tablets are the simplest to remember.

Vaginal estrogen is a separate decision

Low-dose estrogen delivered locally as a cream, tablet, insert, or ring, treating vaginal dryness, discomfort with sex, urinary urgency, and recurrent UTIs. Blood levels generally stay within the normal postmenopausal range.

Three things follow from that:

  • It is not the same conversation as systemic therapy, and many women use it who avoid systemic hormones
  • Added progestogen is generally not needed with low-dose vaginal estrogen
  • These symptoms progress without treatment rather than settling, unlike hot flashes

See is vaginal estrogen safe, GSM and urinary changes, and recurrent UTIs after menopause.

"Bioidentical" is not the opposite of "FDA-approved"

The marketing here is deliberately confusing. Bioidentical means the hormone matches what your body makes. Estradiol patches, gels, sprays, and tablets are bioidentical. Micronized progesterone is bioidentical. There is even an FDA-approved combined estradiol-plus-progesterone capsule.

So you can have bioidentical and FDA-approved. What is different is compounded preparations — custom-mixed, not FDA-approved, not tested for dose consistency or purity — and, importantly, compounded progesterone creams are not considered adequate to protect the uterine lining. See bioidentical hormones explained and compounded versus FDA-approved.

Dose

Standard practice is the lowest dose that controls your symptoms, adjusted at follow-up rather than set once. Starting low and titrating up is normal, and needing an increase is not a failure. Note the exception: women with early or premature menopause typically need higher doses than older women, because the comparison is a body that should still be producing its own — see early and surgical menopause.

What to ask

  • Given my history, would you use oral or transdermal — and why?
  • Do I need a progestogen, and which one? Would a hormonal IUD make sense for me?
  • Cyclical or continuous, given where I am in the transition?
  • Do I also need local vaginal estrogen for the urinary or vaginal symptoms?
  • When do we reassess, and what would we change first if this does not suit me?

Expect the first regimen to be adjusted — hormone therapy is titrated, and the first plan is rarely the final one. See your first three months on HRT, is HRT safe, and what it costs.

If hormones are not right for you, effective alternatives exist and should be offered — see non-hormonal prescription options.

Before that conversation

Walking in organized changes the outcome more than which product you start on. The free 2-minute Menova self-check turns your symptoms into a printable summary, and the free visit prep sheet has space for the history — clots, migraine with aura, family cancer history — that determines which route is appropriate. No account, not a diagnosis, and your answers never leave your device.

Whatever else is going on, unexpected bleeding needs assessing rather than explaining away. Any bleeding after twelve months without periods, bleeding that is new or persistent on hormone therapy, or bleeding after sex should be assessed in person — see bleeding after menopause and bleeding on HRT.

This article is general education, not medical advice. It cannot tell you which hormone, form, or dose is right — only a licensed clinician who knows your full history can do that.

Sources: The Menopause Society — Hormone Therapy, ACOG — Hormone Therapy, NICE NG23 — Menopause, and FDA — Menopause.